23B-008 (17) Lii of Northampton
pi
3 s vU 6 ( Aassarhnartts'
V,Pge „4'lv (INA1
..no DEPARTMENT OP BUILDITNG INSPECTIONS
212 Main Street • Municipal Building _
Northampton, Mass. 01060 toi " ,
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
•
___JEark. lel1Ste_ of f1.0..T. fioofinq
(licensee/permlttec) J
v, :h a principal place of business/residence at:
5113 Kol oite. St. Eastham }� to .Ma. °.loaf ( phone / 113) 5a7 -J17 ?5
( � /
t h' si P)
do hereby certify, under the pains and penalties of perjury, that:
/
I am an employer providing the following worker's compensation coverage for my
emolovees working on this job:
National union Fire.
"Ins- Co. of f''►ttshu c PA VIC31231?bg 40509
(insurance Company) J r (Policy Number) (Expiation Date)
;) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
t :e contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Na.me of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(:::inch :.5.jitio ..1 rbcct if necessary to inchNde information pertain to all ooatradon)
( ) I am a sole proprietor and have no one workdng for me.
( ) I am a home owner performing all the work myself.
NOTE: please be aware that while bocncowncra who employ persona to do •,- rote oonsciioa or rwatir work on a dwelling of
rot nxco than throe units in deft the bomeowocr reside or on the grounds appurteasat thereto arc no generally ooa»dered to be
=RIoye.-3 uoc'.cr the woric&s compensation Ad (GL152ss 1(5)), application by a homeowner for a Gana or permit may evideox the
'. egil tutus of an employer under the Worker'. Coo pemation Act.
I un.ic rtand that a copy of this etatemrnt may be forwarded to the Department of Inrhutrjal Aeeido ti Moe of Imurtooa for t h e
oovec venficnioo ead that failure to scam coot rago ttndet suction 25A of MCI 152 can lad to tbe' impositioe of erimmd peaalt1e$
ocsiw^zg of x Eno of up to S1,500.00 apace imprisonment of up to one year and civil pemlties in the form of a Stop WodtOtder and a
`:no of :;100.00 a day against me.
t /5/''>4: .
Ferdepartmeotal use only
Permit Number
\ .
map# Lot #
�. y Signabne of LiccroseelPermitlu Lai
ki
•
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
5 ■ \ • \ \ as Owner of the subject property
hereby authorize +l• C.1. Too 1 InQ to
act on my behalf, in all matters relative to work authorized by this building permit application.
attached ` - 15 - o g
Signature of Owner Date
1, JNil 2Y k bel is `e 1 1 ►• e.x. ioo in/ / Aqcn 1... , as Owner /Authorized.
(g thereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
. psi eo
Print Name
`1 —1 5 -v
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : JA aair 11 ell s le, ✓ 3 j� ,
License Number
518 Nolyo$ie rat - _ Easy bampton Ma 01021 ` 05-03 - 10
Address Expiration Date
( J i IS) 521 - iiV75
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 1111 No 0
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant):
Registration Number
Address
Expiration Date
•
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
i
Address
Signature Telephone
•
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:. L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
of Parking Spaces
FiIL•
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing 0 Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1 B I ❑
B Business ❑ 2A ❑
E Educational ❑ _� _ 2B I ❑
F Factory ❑ F -1 0 F -2 ❑ 2C ❑
H High Hazard ❑ _ 3A ❑
I Institutional ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage 0 S -1 ❑ S -2 ❑ — 5B I ❑
U Utility ❑ Specify:
M Mixed Use Specify:
S Special Use ❑ Specify:
• . •
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN'US
Existing Use Group: Proposed Use Group: •
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1St 1 st
2 nd
,
3 ` d
3
(d
4th ..
4 th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone El Municipal ❑ On site disposal system
Version1.7 Commercial Building Permit May 15, 2000
De partment use only
City of Northampton Status o Permit
11 ' `" Building Department Curb Cut/Driveway Permit,
212 Main Street Sewer /SepticAvailabitity:
Room 100 waterNVell "Availability;
Northampton, MA 01060 Two Sets of Structural. Plans -�
phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING •
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
2 5 �- • Map Lot Unit
c k.0 0 'C, Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
5 " .■ p 0 box _ (,0 lloka
Name (Print) Current Mailing Address:
( -1i3) 37 1 -9o53
Signature atta Ch ed Telephone
2.2 Authorized Agent:
I aYK - Delis P sot 309 asfi bampton M .
Name (Print) Current Mailing Address: Olds J
(4113) 52 ?•1775
Signature 1 Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed byo permit applicant
1. Building Roofing 2. U C70 • 00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) r (` °�
5. Fire Protection "
6. Total = (1 + 2 + 3 + 4 + 5) . 2O, O0 , 0°
Check Number ( q 2_3
This Sect For Official Use Only
Building Permit Number Date
Issued
Signature:
Date
. Building Commissioner /Inspector of Buildings
File # BP- 2010 -0061
APPLICANT /CONTACT PERSON RCI ROOFING
ADDRESS/PHONE P 0 BOX 309 EASTHAMPTON (413) 527 -4775
PROPERTY LOCATION 267 LOCUST ST
MAP 23B PARCEL 008 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T A. eof Construction: Roofin
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION PRESENTED:
pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
Sig re of Building ficral Date 6 7
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
it LOCUST S#' BP- 2010 -0061
GIS #: COMMONWEALTH OF MASSACHUSETTS
" t 23B- 098 CITY OF NORTHAMPTON
Lot: -000
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2010 -0061
Project # JS- 2010 - 000068
Est. Cost: $20200.00
Fee: $101.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING
Lot Size(sq. ft.): Owner: SILKMILL ASSOCIATES
Zoning: Applicant: RCI ROOFING
AT: 267 LOCUST ST
Applicant Address: Phone: Insurance:
P 0 BOX 309 (413) 527 -4775
EASTHAMPTONMA01027 -0309 ISSUED ON:7/20/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: Roofing
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 7/20/2009 0:00:00 $101.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo